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Transitioning to Cancer Survivorship: Plans of Care

Transitioning to Cancer Survivorship: Plans of Care

ABSTRACT: Abstract: Survivorship care plans have received increasing attention since the 2006 release of the Institute of Medicine report, From Cancer Patient to Cancer Survivor: Lost in Transition. The report strongly recommends that at completion of cancer treatment, clinicians provide patients with a summary of treatment delivered and a detailed plan of ongoing care, including follow-up schedules for visits and testing, as well as recommendations for early detection and management of treatment-related effects and other health problems. Templates have been developed by various groups to support the effort involved in complying with this recommendation. Barriers exist, such as difficulties in accessing information, preparation time involved for busy clinicians, lack of third-party reimbursement, and absence of clear guidelines for follow-up care after cancer treatment. The absence of research related to care plans and patient outcomes also calls their necessity into question. Yet, there is a growing acceptance among oncology physicians and nurses that having a plan of care is an essential component of quality survivorship care.

Recognition of the growing number of cancer survivors in the United States, combined with a greater awareness of the ongoing physical and psychosocial needs after cancer treatment, has created a groundswell of interest in designing quality care initiatives for cancer survivors.

The 2006 Institute of Medicine (IOM) report, From Cancer Patient to Cancer Survivor: Lost in Transition, defined the posttreatment period as a distinct phase of the cancer experience, which requires an individualized plan of care related to the treatment delivered.[1] Informing patients about the treatment they had, what they will need going forward, and who will provide it has been identified as an effective measure to ensure a successful transition from patient to survivor.[2]

The second recommendation of the IOM report states that “patients completing primary treatment should be provided with a comprehensive care summary and follow-up plan that is clearly and effectively explained.” Despite many practical barriers, various organizations have responded by developing templates for implementation of survivorship care plans and nurses and other providers have adopted less formal ways of providing patients with written plans.

What is a survivorship care plan?
A survivorship care plan is the record of a patient’s cancer history and recommendations for follow-up care. The first part, the treatment summary, contains details of the cancer diagnosis and a listing of the various treatments administered. The details of the diagnosis should include the diagnosis date, type of cancer, location, stage, and histology, as well as the names and contact information of the providers and treatment facilities.

Treatment information should include the date range and name of the chemotherapy or biotherapy regimen, drugs, and doses (when relevant); radiation therapy, with the site treated, type of radiation, field, and dose; and any surgical procedures. Additional treatments such as bone marrow transplants and clinical trials should be recorded, as should management of outstanding complications such as chronic graft-versus-host disease following transplant. A comprehensive cancer treatment summary is important for identifying long-term health problems related to the cancer and treatment effects, particularly as the patient transitions away from oncology specialists. In the event of a recurrence or second cancer diagnosis, a record of previous anticancer therapy is essential for safe, effective treatment planning (see Figure 1, “MSKCC Summary of Cancer Treatment and Follow-Up Plan”).

The second part, the follow-up plan, contains specific recommendations for ongoing care as well as health promotional strategies. Follow-up care information includes schedules for visits with the oncology specialist and surveillance testing for cancer recurrence. These recommendations should be based on published guidelines, when available. Examples include an annual clinical breast examination and a mammogram for breast cancer survivors.[3] Colon cancer survivors should have carcinoembryonic antigen blood testing every 3–6 months for 2 years, then every 6 months for 3 years, and colonoscopy at 1 year and then as clinically indicated.[4]

Many survivors continue to experience lasting side effects of cancer and cancer treatment, such as pain, fatigue, neuropathies, and depression. The follow-up plan should identify these long-term effects and the correlating management strategies. The potential for late treatment effects, those toxicities not apparent at the end of treatment but clinically manifested at a later time, as well as recommended surveillance testing, should be noted. For example, the National Comprehensive Cancer Network (NCCN) guidelines recommend that women treated with mantle irradiation for Hodgkin’s lymphoma begin annual mammography at 40 years of age or 8 years following treatment, whichever comes first.[5,6]


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